ANNUAL AFFORDABLE PRIMARY CARE HEALTH MAINTENANCE COVERAGE CONTRACT
Thank you for choosing Dexter Family Practice for your primary care. It is our pleasure to provide you with quality affordable health maintenance coverage.
This agreement is in effect beginning on ____________________ and expires on ___________________. Below is the list of health plans offered. Please choose the plan that best suits your healthcare needs. This plan is payable in advance and each year at renewal time.
I have chosen the ______________plan in the annual amount of $__________. I have enclosed this amount by check/cash/money order/credit card. I agree that this is a non-refundable contract and is my responsibility to renew annually.